M C P T Melbourne College of Professional Therapists "Excellence in Education" SHOULDER AND UPPER LIMB Part 1. Advanced Anatomy 2 Part 2. Assessment 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 1
M C P T Melbourne College of Professional Therapists "Excellence in Education" Suite 5 Ground Floor (Right path way entrance, next door to Lifestyle Gym) Cnr: Ferntree Gully Rd & Jells Rd Wheelers Hill (Vic) 3150 Postal: P.O Box 3171 Wheelers Hill (Vic) 3150 Facsimile: 9560 4523 9562-2280 Some images from: Spence, A P: Basic Human Anatomy, The Benjamin/Cummings Publishing Co, Redwood City 1990 These notes are SDCA PTY LTD trading as Melbourne College of Professional Therapists - MCPT. All rights reserved. No part of these notes may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the express written permission of SDCA PTY LTD. These notes are intended as a guide only, and do not take the place of attendance in scheduled classes. 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 2
A. Osteological Review Sternum: Manubrium Body Xiphoid Process Functions: Mainly for muscle attachment. Transfer of force from limbs through muscular-skeletal structure (its only bony connection to the limb is through the stemo-clavicular joint.) The shoulder/arm hangs on a strut, the clavicle. Clavicle: Humerus: Acts as a strut and is curved for added strength. Allows a force to transfer through the shoulder into the body via the sternum. Rotates as part of the scapulo-thoracic rhythm. Functions include muscle attachments and force transmission. By using labelled diagrams be able to clearly locate these landmarks and understand their function: Head Neck (anatomical & surgical) Tubercles (greater & lesser) Bicipital groove Deltoid tuberosity Supracondylar ridge Epicondyles (medial & lateral) Trochlea Capitulum Olecranon fossa Scapula: Functions as point of attachment for muscles and ligaments. Involved in scapulo-thoracic / scapulo-humeral rhythm. By using labelled diagrams be able to clearly locate these landmarks and understand their function: Borders (margins) Medial (vertebral), Lateral (axillary), Angles (superior & inferior), Processes (acromion & coracoid) Fossa (glenoid, supraspinous, infraspinous, subscapular) Spine of scapula Tubercles (supraglenoid & infraglenoid) Ribs: Occipital: Attached to sternum via costal cartilage anteriorly. Posteriorly attached to costal facets of transverse processes and bodies of T1- T12. Act as attachment sites for Serratus (Anterior & Posterior), Subclavius, Scalenes and Pectorals (Major & Minor) Point of attachment for Trapezius. 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 3
Cervical Vertebrae: Thoracic Vertebrae: Attachment for Levator Scap., Rhomboids, Scalenes, Splenius, Semispinalis, Multifidi, Sub-Occipital and Ligamentum Nuchae. Attachment for Trapezius, Rhomboids, Latissimus Dorsi, Serratus Posterior Superior, Semispinalis & Multifidis. Radius: Ulna: Carpals: By using labelled diagrams be able to clearly locate these landmarks and understand their function: Head Fovea capitus Radial (Bicipital) tuberosity Ulna notch Styloid process Carpal articular surface By using labelled diagrams be able to clearly locate these landmarks and understand their function: Head Olecranon process Coronoid process Radial notch Styloid process Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid Capitate Hamate Metacarpals: 1-5 Phalanges: 1-5 (proximal, middle, distal) B. Kinesiological Review Shoulder Girdle: Shoulder Joint: (Ball & Socket) Elbow Joint: (Hinge) Radio-Ulna Joint (Pivot) Wrist (Radio-carpal) (Biaxial) Trapezium/Metacarpal 1 Elevation, Depression, Retraction (Adduction), Protraction (Abduction), Upward Rotation. Flexion, Extension, Internal (Medial) Rotation, External Lateral) Rotation, Adduction, Abduction, Horizontal Flexion, Horizontal Extension, Circumduction. Flexion, Extension Pronation, Supination Flexion, Extension, Radial deviation (Abduction), Ulna deviation (Adduction) Weak circumduction 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 4
Metacarpal-Phalangeal (Biaxial) Interphalangeal (Biaxial) Flexion, Extension, Abduction, Adduction Flexion, Extension C. Arthrology Complete following tables to closely examine the structures and movements of each of the specified joints. D. Skeletal Muscles Likewise for each of the specified muscles in the accompanying tables complete their respective origins, insertions, functions (actions) and how they can be best palpated. Movers of the Wrist & Hand Joints Flexors Superficial Layer: Intermediate Layer: Deep Layer: Flexor Carpi Ulnaris Palmaris Longus Flexor Carpi Radialis Flexor Digitorum Superficialis Flexor Digitorum Profundus Flexor Pollicis Longus Extensors Superficial Layer: Deep Layer Extensor Carpi Ulnaris Extensor Digitorum Minimi Extensor Digitorum Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Abductor Pollicis Longus Extensor Indicis Extensor Pollicis Longus Pollicis Brevis Intrinsic muscles in hand. 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 5
E. Other Structures Circulatory suprascapular artery and vein thoracoacromial trunk subclavian artery and vein axillary artery and vein humeral circumflex brachial artery and vein basilic and cephalic veins radial and ulna arteries Lymphatics ducts draining arm, axilla and breast axillary nodes subclavian nodes Bursae Nerves between subscapular tendon and capsule between superior and middle glenohumeral ligaments between infraspinatus tendon and capsule between deltoid and capsule (subacromial) upper surface acromion between coracoid process and capsule posterior to coracobrachialis between teres major and long head of triceps brachii anterior and posterior to latissimus dorsi Refer accompanying Table CERVICAL MUSCLE NERVE 11th cranial Sternocleidomastoid Spinal accessory nerve 11th cranial Trapezius Spinal accessory nerve C3-C4 Levator Scapulae C5 Brachioradialis C5 Rhomboid Major Dorsal Scapular nerve C5 Rhomboid Minor Dorsal Scapular nerve C5 Teres minor Axillary nerve C5-C6 Biceps Brachii Musculocutaneous Nerve C5-C6 Brachialis Musculocutaneous Nerve C5-C6 Corachobrachialis Musculocutaneous Nerve C5-C6 Deltoid -Anterior Axillary Nerve C5-C6 Deltoid Medial Axillary Nerve C5-C6 Deltoid -Posterior Axillary Nerve C5-C6 Infraspinatus Subscapular nerve C5-C6 Subscapularis Subscapular nerve C5-C6 Supraspinatus Supraspinatus Suprascapular nerve C5-C6-C7 Serratus anterior Long Thoracic Nerve C5-T1 Pectoralis major C6-C7 Pronator teres Median nerve C6-C8 Latissimus dorsi C6-C8 Triceps Brachii Radial Nerve C8-T1 Pronator quadratics Median Nerve (Scapular retraction) 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 6
Arthrology Joint Bone/Surfaces Ligaments Movements Costo Vertebral (bodies) Costo Vertebral (Transverse Pr) Sternoclavicular Acromio Clavicular Gleno Humeral Elbow 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 7
Prox Radio Ulna Joint Bone/Surfaces Ligaments Movements Radio Carpal Intercarpal Carpo Met - Carp Meta Carp - Phal Inter-Phalangeal 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 8
Muscle Origin Insertion Functions Palpation Trunk to Scapula Trapezius Serratus Anterior Rhomboid Major Rhomboid Minor Pectoralis Minor Levator Scapulae 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 9
Muscle Origin Insertion Functions Palpation Scapula to Humerus Deltoid Superspinatus Infraspinatus Teres Minor Subscapularis Teres Major 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 10
Muscle Origin Insertion Functions Palpation Trunk to Scapula Coraco Brachialis Biceps Brachii Triceps Trunk to Humerus Pectoralis Major Latissimus Dorsi 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 11
Muscle Origin Insertion Functions Palpation Muscles causing movement at the elbow Biceps Brachii Triceps Anconeus Pronator Teres Pronator Quadratus 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 12
Anterior view of muscles of shoulder joint, superficial layer. Posterior view of muscles of shoulder joint, deep layer Anterior view of muscles of shoulder joint, deep layer. 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 13 Muscular reinforcement of shoulder joint. (a) Anterior view (b) Posterior view
Anterior muscles of shoulder girdle. Posterior muscles of shoulder girdle, deep layer 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 14
Joint Movements 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 15
Deltoid (posterior) Teres Major Latissimus Dorsi Muscles that contract to produce hyperextension of the upper extremity Muscles that contract to produce abduction of the upper extremities Biceps muscles of the arm 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 16
Muscles that contract to produce outward rotation of the arm and accompanying adduction of the scapula Brachioradialis Pronator Teres Superficial muscles on front of right forearm 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 17
Triceps (long head) Triceps and supinator Deep muscles on front of right arm 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 18
Examples of grasps. The muscular involvement depends on the nature of the grasp 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 19
Shoulder Flexors Origin Insertion Action/s Pectoralis Major Clavicle, sternum, ribs 1-6, abdominal & obliques Lat. lip of bicipital groove on humerus of humerus Horiz. adduction, flexion & inward rotation Coracobrachialis Coracoid process on scapula Mid medial shaft of humerus Draws arm forward (flex) & inward (adduct) Biceps Brachii Supraglenoid tubercle & coracoid process Radial tuberosity & bicipital aponeurosis Weak arm flexion & adduction. Strong elbow flexion & supination Anterior Deltoid Clavicle (ant / lat) Deltoid tuberosity Horizontal adduction, medial rotation of arm Extensors Posterior Deltoid Spine of scapula Deltoid tuberosity Horizontal abduction, lateral rotation of arm Abductors Middle Deltoid Spine of scapula acromion, lat clavicle Deltoid tuberosity Abducts arm Supraspinatus (*) Supraspinous fossa on scapula Greater tubercle on humerus Abducts arm Adductors Latissimus Dorsi T7 - T12 & lumbar. LI -L5 and iliac crest Bicipital groove on humerus Extension, adduction & inward rota. of arm Teres Major Lower lateral border of scapula Medial lip of bicipital groove on humerus Adduction & inward rotation of arm Triceps (Long Head) Infraglenoid tubercle on scapula Olecranon process on ulna Adducts humerus Rotators Infraspinatus (*) Teres Minor (*) Infraspinous fossa on scapula Lateral border of scapula Posterior greater tubercle on humerus As above Lateral (outward) rotation of arm Lateral (outward) rotation of arm Subscapularis (*) Subscapular fossa (anterior surface) Lesser tubercle on humerus Medial (inward) rotation of arm 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 20
Elbow Biceps Brachii Origin Supraglenoid tubercle (long head) & coracoid process (short head) Insertion Radial tuberosity Action/s Flexion and supination Triceps Infraglenoid tubercle (long head) & posterior humerus (med & lat hds) Olecranon process on ulna Extension at elbow Brachialis Lower anterior surface on humerus Ulna tuberosity near coronoid process Flexes elbow when hand is pronated Brachioradialis Supracondylar ridge on lateral distal humerus Distal lateral surface of radius near styloid process Flexes elbow when hand in semipronation / semisupination Forearm Pronator Teres Sup. medial epicondyle on humerus Middle, lateral radius Pronates & flexes forearm Pronator Quadratus Palmar surface of ulna (distal quarter) Palmar surface of radius Pronates forearm Supinator Lateral epicondyle on humerus & ulna crest Lateral surface of upper radius Supinates forearm Common flexors (palmar side) Medial epicondyle of humerus. Upper & mid ant. radius & ulna Palmar surface of metacarpals & phalanges Flexion of wrist, fingers & thumb Common extensors (radial side) Lateral epicondyle of humerus Dorsal surface of metacarpals & phalanges Extend, abduct/adduct wrist & hand 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 21
ASSESSMENT OF SHOULDER & UPPER LIMBS A. Medical Assessment of Shoulder & Upper Limb Pain History Examination Range of Motion (ROM) - Active - Passive Resisted Movement - Abduction /Adduction " - Rotation (Internal & external) Pathologies Soft tissue lesions Sub-acromial Gleno-humeral Adhesive capsulitis A-C joint Special Tests Biceps integrity test Supraspinatus integrity test Impingement test Stability Investigations X-rays Diagnostic Ultrasound CT scan (arthrogram) MRI Arthroscopy Hydro dilatation B. The Physiotherapy Approach to Shoulder & Upper Limb Pain Scapulo-humeral movement Biomechanics Swimming Throwing sports Tennis serve Source of Pain Muscle strain Tendinitis Impingement Referred pain 2006 MCPT Advanced Anatomy and Assessment 1 Diploma (HLT50307) Version 1 Feb 2006 22
Capsular Muscle strain - Active movement; resisted movement Tendinitis - phases - causes - management Impingement - assessment -? secondary to instability - management Referred Pain - Cervical spine - Thoracic spine - Neural Tension - Upper Limb Tension Test (ULTT) - soft tissue involvement - other causes - Active trigger points Capsular / Ligamentous origins - Passive movement tests C. Suggested General Assessment by Remedial Masseurs T = O = T = A = P = S = TALK - find out history of injury, (what, when, where, how etc) - What are the symptoms described by the patient? OBSERVE - for signs, abnormalities, deformities, swelling, bruising etc. TOUCH - Feel for tenderness/pain, fluid, crepitus, swelling, heat etc. Know landmarks and check for asymmetry. Compare injured with uninjured side. ACTIVE MOVEMENT - Check ROM PASSIVE MOVEMENT - Check ROM before onset of pain. SKILLS TEST - If the patient "passes" the above inhibiting "tests" check they are pain free with full movement when performing their specific sporting skills before advising a return to their sport. Note, however, that training may continue with non injured parts during the recovery phases. Check STABILITY of joints for ligamentous damage.* SPECIAL TESTS* REFERRED PAIN* * (Refer Hoppenfeld pp 32-34, 56-57. 100-104) 2006 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb 2006 23
ASSESSMENT OF THE SHOULDER SHOULDER ADDUCTORS Length 1.Passive abduction (180o) Strength Resisted abduction 2. Isolates point at which scapula starts to move SHOULDER ABDUCTORS Supraspinatus & Deltoid SHOULDER MEDIAL ROTATORS 1. 2. Isolates Subscapularis when arm held in 90o abduction SHOULDER LATERAL ROTATORS PASSIVE HORIZONTAL ADDUCTION (A-C JOINT) LONG HEAD OF TRICEPS RESISTED FLEXION OF BICEPS 2006 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb 2006 24
ASSESSMENT OF THE ELBOW Length Strength ELBOW FLEXORS 1. Biceps Brachii 2. Brachialis 3. Brachioradialis 1. 2. 3. ELBOW EXTENSORS PRONATORS SUPINATORS LATERAL EPICONDYLITIS "Tennis Elbow" RESISTED TEST MEDIAL EPICONDYLITIS "Golfer's Elbow" RESISTED TEST 2006 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb 2006 25
ASSESSMENT OF THE WRIST Length Strength PASSIVE CARPAL PRONATION PASSIVE CARPAL SUPINATION PASSIVE WRIST FLEXION PRONATORS PASSIVE WRIST EXTENSION SUPINATORS PASSIVE WRIST ABDUCTION PASSIVE WRIST ADDUCTION 2006 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb 2006 26
PHYSICAL EXAMINATION OF THE SHOULDER Reference: Hoppenfeld, S. "Physical Examination of the Spine & Extremities" pp. 1-34 BONY PALPATION Suprastemal Notch Stemoclavicular Joint Clavicle Coracoid Process Acromioclavicular Articulation Acromion Greater Tuberosity of Humerus Bicipital Groove Spine of Scapula Vertebral Border of Scapula Superior Angle of Scapula Inferior Angle of Scapula SOFT TISSUE PALPATION Rotator Cuff Subacromial & Subdeltoid Bursae The Axilla Prominent Muscles RANGE OF MOTION Active ROM Tests Quick Tests Passive ROM Tests Abduction 180o Adduction 45o Flexion 90o Extension 45o Internal Rotn. 55o External Rotn. 40-45o NEUROLOGIC EXAMINATION Muscle Testing Reflex Testing Sensation Testing SPECIAL TESTS The Yergason Test Drop Arm Test Apprehension Test for Shoulder Dislocation EXAMINATION OF RELATED AREAS 2006 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb 2006 27
PHYSICAL EXAMINATION OF THE ELBOW Reference: Hoppenfeld, S. "Physical Examination of the Spine & Extremities" pp. 35-57 INSPECTION Carrying angle Swelling Scars BONY PALPATION Medial Epicondyle Medial Supracondylar Line of Humerus Olecranon Ulna Border Olecranon Fossa Lateral Epicondyle Lateral Supracondylar Line of Humerus Radial Head SOFT TISSUE PALPATION Medial Aspect Ulna Nerve Wrist flexor/pronator muscle group (Pronator Teres, Flexor Carpi Radialis, Palmaris Longus, Flexor Carpi Ulnaris). Medial Collateral Ligament Supracondylar Lymph Nodes Posterior Olecranon Bursa Triceps Lateral Wrist extensors (Brachioradialis, Extensor Carpi Radialis Longus & Brevis) Lateral Collateral Ligament Annular Ligament Anterior Cubital Fossa Biceps Tendon Brachial Artery Median Nerve RANGE OF MOTION Active ROM Tests Flexion 135o+ Extension 0o-5o Supination 90o Pronation 90o Passive ROM Tests Flexion & Extension Supination & Pronation NEUROLOGIC EXAMINATION Muscle Testing Reflex Testing Biceps Reflex (C5) Brachioradialis Reflex (C6) Triceps Reflex (C7) Sensation Testing SPECIAL TESTS Tests for Ligamentous Stability Tinel Sign Tennis Elbow Test 2006 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb 2006 28
PHYSICAL EXAMINATION OF THE WRIST & HAND Reference: Hoppenfeld, S. "Physical Examination of the Spine & Extremities" pp. 59-104 RANGE OF MOTION Active ROM Passive ROM Wrist: Flexion Extension Ulna deviation Radial deviation Metacarpo-phalangeal joint: Flexion Extension Finger abduction Finger adduction Thumb abduction (palmar abduction) Thumb adduction (dorsal adduction) 80o 70o 30o 20o 90o 30o-45o 20o 0o 70o 0o Fingers - opposition NEUROLOGIC EXAMINATION Muscle testing Wrist extension C6 Wrist flexion C7 Finger extension C7 Finger flexion C8 Finger abduction T1 Finger adduction T1 Thumb extension Thumb flexion Thumb abduction Thumb adduction Pinch mechanism (thumb & index finger) Opposition of thumb & little finger 2006 MCPT Advanced Anatomy and Assessment 1 Diploma of Remedial Massage (HLT 50302) Version 1 Feb 2006 29